Renal Transplantation

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Contents 1 Introduction 2 Indications 3 Contraindications 4 Procedure 5 Radiology 6 Complications 7 Management 8 More General Terms 9 Additional Terms 10 References

Introduction

• The 1st renal transplant was performed in 1954.

Indications

• end-stage renal disease*
• the patient must not have cancer
• infections must be erradicated
• cholecystectomy must be done for gallstones

• * treatment of choice for eligible patients

Contraindications

• active infection, excluding HIV [5]
• active malignancy
• dementia
• significant heart, lung or liver disease
• a chronically debilitated state
• substance abuse
• non-compliant patients

Procedure

• Benefits: (with good allograft function, GFR > 50 mL/min)

• resolution of anemia
• return to full-time employment
• return of normal endocrine, sexual & reproductive function
• enhanced energy levels
• return to strenuous exercise
• having children is feasible
• resolution of autonomic neuropathy in diabetics
  

• Donors:

• living

• > 18 years of age
• without systemic or renal disease

• cadaveric

• > 6 months old
• without infection or malignancy (except non-metastasizing brain tumor)
  

• Evaluation:

• evaluation for coronary artery disease ( CAD)
• viral serologies

• hepatitis B & hepatitis C
• HIV
• cytomegalovirus ( CMV)

• dental exam for dental abscesses

Radiology

• post- transplant DPTA/hippuran renal scan

Complications

• surgical complications

• renal artery stenosis (late complication)
• ureteral obstruction or leak
• lymphocele

• graft rejection

• graft failure commonly due to chronic rejection
• acute tubular necrosis occurs in 20-50% of patients after transplantation
• stages of rejection

• hyperacute (hours)
• acute (days to years)
• chronic (months to years)

• treat only acute stages of rejection
• graft rejection may occur after 7-10 years
• graft rejection more common when

• kidney is from older donor
• kidney is transplanted into younger recipient [7,8]

• recurrent allograft renal disease

• membranoproliferative glomerulonephritis
• membranous nephropathy
• focal segmental glomerulosclerosis

• clinically, most problematic
• treat with aggressive plasmapheresis (pheresible protein)

• diabetes mellitus
• primary hyperoxaluria
• hemolytic uremic syndrome
• IgA nephropathy (generally not clinically significant)

• opportunistic infections*

• BK virus associated nephropathy with immunosuppression

• cardiovascular complications*
• hyperlipidemia
• cancer (1%)

• skin cancer
• sarcomas - Kaposi's sarcoma
• lymphoma ( Epstein-Barr virus ( EBV) associated)
• solid tumors, lung cancer [6]

• erythrocytosis

• no leukocytosis or thrombocytosis
• phlebotomize if hematocrit > 52
• ACE inhibitors

• renal tubular acidosis (RTA)

• both proximal (type 2) & distal (types 1,4)
• type 4 RTA most common

• urolithiasis (uncommon)
• corticosteroid-related complications

• aseptic necrosis of hip or knee
• increased risk of fractures

• gout
• underlying kidney disease that may recur after renal transplantation

• focal segmental glomerulosclerosis
• IgA nephropathy
• diabetic nephropathy
• lupus nephritis
• membranous nephropathy
• hemolytic uremic syndrome

• * 2 most common causes of death

Management

• immunosuppression unless donor is identical twin

• induction therapy

• thymoglobulin depletes lymphocytes
• IL2 receptor antibodies

• daclizumab
• basiliximab, depletes lymphocytes
• targets IL2 receptor
• causes lymphocyte arrest

• alemtuzumab targets CD52,
• muromonab-CD3 targets CD2, depletes lymphocytes

• maintenance therapy

• lifetime immunosuppression is required
• agents

• tacrolimus
• cycloporine
• rapamycin
• azathioprine
• myocophenoloate
• prednisone

• prognosis:

• 95% 1 year & 88% 5 year patient survival
• 80% 1 year & 70% 5 year cadaveric graft survival
• graft survival is better in recipients of living kidneys

• 95% 1 year & 89% 5 year living graft survival
• 5-10% less in black Americans, recipients of a 2nd kidney & highly sensitized individuals

• old organs transplanted into young recipients have by far the highest rejection rates [8]
• old organs may be successfully transplanted into older patients [8]
• preemptive renal transplantation before dialysis & transplantation shortly after initiation of dialysis associated with patient & allograft survival advantage
• HIV patients likely to do as well as other patients, albeit with higher transplant rejection rates [5]

• renal transplant patients with gout:

• mycophenolate rather than azathioprine may permit use of allopurinol

• conception/ pregnancy

• women should wait at least 1-2 years after transplantation prior to conception
• considered high-risk pregnancy
• pregnancy not recommended if serum creatinine > 2 mg/dL [2]

More General Terms

• organ/tissue transplantation

Additional Terms

• DPTA/hippuran renal scan
• end-stage renal disease (ESRD)
• renal graft rejection

References

1. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 618
2. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, American College of Physicians, Philadelphia 1998, 2009
3. Harrison's Principles of Internal Medicine, 13th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1994, pg 1282
4. FDA Medwatch [1]
5. Stock PG et al. Outcomes of kidney transplantation in HIV-infected recipients. N Engl J Med 2010 Nov 18; 363:2004. PMID: [2]
   - Szczech LA. Tackling the unknowns in HIV-related kidney diseases. N Engl J Med 2010 Nov 18; 363:2058. PMID: [3]
6. Engels EA et al. Spectrum of cancer risk among US solid organ transplant recipients. JAMA 2011 Nov 2; 306:1891. PMID: [4]
7. de Fijter JW The impact of age on rejection in kidney transplantation. Drugs Aging. 2005;22(5):433-49. Review PMID: [5]
8. Tullius SG, Milford E. Kidney allocation and the aging immune response. N Engl J Med 2011; 364:1369-1370 PMID: [6]
9. Kidney Transplantation: NIH Institute and Center Resources [7]
10. National Guideline Clearinghouse Immunosuppressive therapy for renal transplantation in adults. National Institute for Health and Clinical Excellence ngc-guideline: [8]
    - Donor sepsis. Caring for Australasians with Renal Impairment ngc-guideline: [9]
    - Assessment of donors with sub-optimal kidney function/structure. Caring for Australasians with Renal Impairment ngc-guideline: [10]
    - Donor cancer. Caring for Australasians with Renal Impairment ngc-guideline: [11]
    - Non-heart-beating donors. Caring for Australasians with Renal Impairment ngc-guideline: [12]
    - Best evidence statement (BESt). Readiness for transition to adult care: pediatric kidney transplant patients. Cincinnati Children's Hospital Medical Center ngc-guideline: [13]
    - Annual screening. In: Guidelines on renal transplantation. European Association of Urology ngc-guideline: [14]
    - Graft and patient survival. In: Guidelines on renal transplantation. European Association of Urology ngc-guideline: [15]
    - Immunological complications. In: Guidelines on renal transplantation. European Association of Urology ngc-guideline: [16]
    - Immunosuppression after kidney transplantation. In: Guidelines on renal transplantation. European Association of Urology ngc-guideline: [17]
    - Kidney donation. In: Guidelines on renal transplantation. European Association of Urology ngc-guideline: [18]
    - Kidney recipient. In: Guidelines on renal transplantation. European Association of Urology ngc-guideline: [19]
    - Malignancy. In: Guidelines on renal transplantation. European Association of Urology ngc-guideline: [20]
    - Matching of donors and recipients. In: Guidelines on renal transplantation. European Association of Urology ngc-guideline: [21]
    - Transplantation techniques. In: Guidelines on renal transplantation. European Association of Urology ngc-guideline: [22]

renal transplantation